2012

N. Champagne1, M. Abreu1, S. Nobrega1,M. Goldstein-Gelb2, M. Montano2,I. Lopez2, J. Arevalo2, S. Bruce3, L. Punnett11UMass Lowell, Lowell, MA; 2 MassCOSH,

Boston, MA; 3 Boston Worker’s Alliance,

Boston, MA, USA11/8/2012

Obesity/Overweight and theRole of Working Conditions:

A Qualitative, Participatory Investigation

STUDY REPORT

The Center for the Promotion of Health in the New England Workplace at theUniversity of Massachusetts Lowell and the University of Connecticut, theMassachusetts Coalition for Occupational Safety and Health (MassCOSH), andthe Boston Worker’s Alliance (BWA).

This project was supported by Grant UL1RR031982 from the National Center forResearch Resources and the National Center for Advancing TranslationalSciences, National Institutes of Health. The content is solely the responsibility ofthe authors and does not necessarily represent the official views of the NIH.

Additional research support provided by Grant 1 U19 OH008857 from the U.S.National Institute for Occupational Safety and Health. This material is solely theresponsibility of the authors and does not necessarily represent the official viewsof NIOSH.

Table of Contents

Obesity/Overweight and the Role ofWorking Conditions:A Qualitative, Participatory Investigation

Table of Contents

Executive Summary ............................................... 2Background............................................................. 7Methodology .........................................................11Results...................................................................14Recommendations ...............................................22Conclusions ..........................................................25Appendix: Demographics………………………....26Endnotes ...............................................................27

2

Executive Summary

Executive Summary

The rising rates of obesity in the U.S. are generating significant concern, and a variety of efforts

are underway to slow the trend. Most interventions target individual behaviors related to weight

gain (diet and physical activity), and the impact of the work environment on obesity has been

under-appreciated to date. Although the work environment has been recognized as an

important factor for other health and safety outcomes, the impact of working conditions on

overweight and obesity has been largely ignored. Additionally, with 3.8 million workers earning

at or below the federal minimum wage and 19.4% of those workers spending 40 hours or more

per week on the job, it is imperative to examine the impact of work on health and weight ,

especially for low-income workers, given the socioeconomic disparities that exist in rates of

obesity in the United States.

This study investigated whether lower-income workers perceived any factors in the workplace

that have an effect on their weight status. The research was carried out through a community

partnership between University researchers and worker leaders from organizations representing

lower income workers. Initially, anecdotes shared by lower income workers with worker

advocacy organizations spurred the generation of this study.

Ninety-two low-wage Latino and Black or African American workers contributed to the study.

Eight focus groups were conducted with a total of 63 workers in the Greater Boston area, both

male and female, Latino and Black or African American. Another four workers participated in in-

depth interviews to augment the results of the focus groups. Three additional stakeholder

meetings were conducted with 25 low-wage workers to review and comment on the preliminary

findings of the study and seek additional input on recommendations.

Participants came from a variety of industries, including housekeeping/cleaning, restaurant/food

service, construction, healthcare/human services, and manufacturing. They described a range

of factors influencing their diet, exercise, and body weight – notably, time pressure,

psychological stress, and decreased ability to exercise after injury or illness (i.e., depression).

These findings are supported by additional in-depth interviews with lower-income workers,

examination of national data, and a review of existing scientific literature. These combined

inputs provide a multifaceted picture of the role of working conditions in the development of

overweight/obesity among lower-income workers.

3

Executive Summary

SignificanceObesity is widely recognized as a significant public health issue, contributing to numerous

preventable chronic diseases including heart disease, stroke, cancer, and diabetes. According

to the Centers for Disease Control and Prevention, more than one-third of U.S. adults (35.7%)

are obese.2 Additionally, it is well established that overweight and obesity rates are

disproportionately higher for lower-income individuals, and in particular, lower income Black or

African Americans and Latino Americans.

While it is recognized that overweight and obesity disproportionately affect lower-income

individuals, most studies have focused upon how increased income facilitates greater access to

healthier lifestyles (ability to afford healthier foods, live in safer neighborhoods with more access

to recreational spaces, etc.). Other studies show sedentary jobs as a contributing factor to

overweight and obesity. However, this is often not the experience of lower income workers.

These workers are more likely involved in physically demanding work, and are often too fatigued

or debilitated to enjoy physical activity in their leisure time.

As a result, the programs initiated to date tend to focus on encouraging individuals to increase

physical activity either before work (such as walk-to-work programs), or during work (such as

providing treadmills or encouraging the use of stairs). Other interventions focus on educating

workers about nutrition and healthy eating habits. However, these traditional interventions fail to

address the factors influencing obesity in the workplace, as experienced by the millions of low-

income workers in the United States.

The present study aims to explore how working conditions faced by lower-income workers affect

weight status, a question not previously addressed in the literature.

4

Executive Summary

FindingsThrough the eight focus groups and four in-depth interviews, the low-wage workers conveyedseveral factors that they perceive to have an impact on body weight. The main results arehighlighted below:

1. Physically Demanding Work

“I don’t have the desire to do exercise after standing for 15-16 hours…I just wantto eat and sleep…The next day is the same thing all over again.”

Having a physically demanding job often resulted in illnesses and/or injuries, influencingworkers’ ability to participate in physical activity outside of the job.

Physical fatigue from work played a role in the quantity of food consumed at the end ofthe workday.

2. Psychosocial Stressors

“The work that three people used to do is given to one person. That createsmore stress and eating more…”

Experiences of high demands in the workplace led some workers to feel stressed andconsume more high-calorie foods, such as candy and soda.

Workers reported feelings of exhaustion, having multiple jobs and responsibilities, andscheduling as elements of a heavy workload.

3. Time Pressure

“At 10:00 a.m., they give me a 15-minute break. I don’t have time to eat healthyfood, even if I bring homemade food. I don’t have time to do exercise.”

Many workers reported having only 15 minutes to eat during their working hours, makingit difficult to prepare and eat healthy food in a short period of time.

Female workers often discussed the interaction between work and family, specificallyhow the combination of responsibilities at work and at home reduced available time toengage in physical activity and eat healthy. For these workers, reliance on conveniencefoods was a particularly important time-saving strategy.

4. Food Environment at Work

“I cannot even talk about the cafeteria because that ‘cafeteria’ is in the corner of adirty and unsanitary room.”

Workers reported having limited access to healthy food, due to their limited mealtimeand the location of their workplace.

Many workplaces fail to provide workers with the appropriate equipment and space toeat meals, influencing workers’ diet.

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Executive Summary

RecommendationsTo enhance the working conditions reported by lower-wage workers in the study, the following

recommendations are aimed at employers, policymakers, and stakeholders:

Recommendations for Employers:

Breaks and Meals

Allow sufficient time for breaks and meals; provide the state-mandated 30 minutesconsecutively, as a single break.

Support daily communication of rest and meal break times to employees, to reduce anxietyabout hunger and to facilitate healthy meal planning.

Provide a clean space for eating, with sufficient functional equipment (refrigerator,microwave) for the number of employees on site.

Workload and Scheduling

Determine physical workloads that are moderate enough to avoid excessive fatigue and riskof injury.

Institute health and safety programs that identify and reduce or eliminate ergonomichazards.

Involve workers in scheduling decisions for shift work and overtime to promote familybalance and mental health.

Other

Encourage supportive supervisory and management styles.

Promote programs that identify and eliminate bullying and sexual harassment.

Select group health coverage and third party service contractors that address workingconditions and are sensitive to the needs of low-wage workers.

Establish worker-management committees that incorporate health, safety, and wellness.

Recommendations for Government and Public Policy-makers:

Address working conditions as part of workplace obesity or “wellness” programs.

When developing employer tools and resources for promoting employee health, includerecommendations and strategies for addressing working conditions that affect health.

Include occupational health experts in obesity reduction and other wellness advisorycouncils.

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Executive Summary

Increase funding for applied research on the impact of improved working conditions andmeal policies on obesity reduction.

Routinely incorporate information about occupation and industry in the Behavioral RiskFactor Surveillance Survey (BRFSS) and report on patterns of obesity by industry,occupation, and other demographic characteristics

Develop and implement a state-specific BRFSS module to collect additional information onworking conditions related to diet and exercise behaviors.

Recommendations for Insurance Companies

Establish insurance rate reduction programs for employers that improve workplace healthand safety. Extend these benefits to employers who make work environment improvementsthat affect obesity.

Track participation in Worksite Health Promotion by job type; Use this data to identify andaddress potential barriers to participation for low-wage workers.

Recommendations for Funders

Increase funding for intervention research on the impact of improved working conditions andmeal policies on obesity reduction, especially among low-income workers.

Promote funding for employer and worker initiatives that contribute to the improvement ofworking conditions to support good nutrition, physical activity, and psychosocially strongworkplaces.

Recommendations for Unions and Worker Groups

Educate workers about the impact of working conditions on weight, and engage them inparticipatory programs to increase the health status of lower income workers.

Establish union health and safety committees that integrate issues related to weight andwellness.

Background

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BackgroundObesity has become a significant public health issue in the United States and elsewhere.

Obesity rates among U.S. employed persons have risen substantially in recent years, but with

important differences by race and ethnicity, socioeconomic status, and job type. Black workers

have the highest rates of obesity among U.S. working adults, especially among women.1

Additionally, Latinos have a higher Body Mass Index (BMI) as compared to non-Latino whites.2

Lastly, in certain occupations, obesity rates vary by gender. Among motor vehicle operators and

material moving equipment operators, rates are higher for men; while women are more likely to

be obese in occupations like cleaning and building services.

The workplace affects health in various ways. Physical working conditions can increase

the likelihood of injury and illness, particularly when the work is physically demanding.3 Work

that entails moving heavy materials or repetitive motions can cause musculoskeletal disorders

like low back pain or tendinitis. Conversely, sedentary occupations requiring little to no

movement may also have a negative influence on health, through mechanisms such as

impaired circulation or higher incidence of obesity.

Aspects of work organization – notably work scheduling – can greatly affect health. For

example, working long hours or night shifts reduces sleep quality and quantity, leading to fatigue

and chronic health problems. The combination of sleep deprivation and fatigue increases risk of

injury at work, since the ability to focus on work tasks is reduced. Moreover, long or highly

variable work schedules can disrupt healthy routines like the preparation and consumption of

nutritious meals, or engagement in regular physical activity.

The effects of an individual’s working hours not only affect the health behaviors of the

individual, but their family as well.3 Long workdays and working multiple jobs can reduce time

available for family dinners, with some parents resorting to calorie-dense fast food and

convenience foods to feed their families.4 Furthermore, competing demands between work and

family may often leave parents feeling stressed and exhausted, which can interfere with

motivation and energy available for leisure time physical activity. Among low-wage employed

parents, the ability to manage food choices is negatively impacted by stressful working

conditions. In particular, low job security and satisfaction, as well as poor access to food at

work, are related to more meals consumed outside the home and therefore, fewer family

meals.5

Background

8

Studies of employed African American women show associations between lack of time

and low physical activity, as well as between stressful work and overeating.6, 7 Findings have

been attributed to multiple demands, not only those experienced in the workplace, but at home

as well. Furthermore, these women have identified physical activity as something pursued by

White women, demonstrating cultural differences in perception of physical activity.

Working long hours is also associated with high Body Mass Index (BMI) among transit

workers, due to workers’ food choices and accessibility to food at work.7 These transit workers

find it difficult to eat fruits and vegetables at work, and are more likely to consume food from

vending machines. Since vending machines tend to be limited in providing healthy food options,

workers may believe it is challenging to eat healthy at work.7 Therefore, it is important to

consider the food environment as an important determinant of overweight/obesity in the

workplace.

Similar associations between long work hours and weight status have been found

among nurses, a physically demanding occupation.8 Nurses who work long shifts are more

likely to be overweight or obese, with disrupted sleep patterns, poorer perceptions of health, and

less physical activity.8 Limited sleep (less than 6 hours per night), a common outcome for shift

workers, has been correlated with changes in appetite/satiety regulation, metabolism, and

insulin sensitivity, as well as a reduction in available energy to engage in physical activity.8,9 As

a result, long work hours and shift work contribute to the risk of overweight/obesity among

nurses. However, these health outcomes have not only been linked to shift work and long work

hours, but to job stress as well.8

Stress on the job is known to contribute to ill health by activating certain biological and

behavioral responses. Workplace stress is caused by psychosocial conditions like high job

demands and low “job control” (few opportunities for decision-making), both of which have been

identified as risk factors for higher Body Mass Index.3,10 Examples of documented health

outcomes associated with job stress include cardiovascular disease morbidity and mortality,

anxiety, and depression.10 Less recognized is the influence of psychosocial stress on health

behaviors and the risk of obesity.10 In particular, stressful working conditions can influence food

choices, eating patterns, and low levels of leisure-time physical activity. African American

women who experienced job-related stress have reported overeating, late-night binges, and

Background

9

increased fast food consumption.6 Experiences of racism and sexism in the workplace have

also been documented as contributing to emotional eating and weight gain.11 Additionally,

stressful working conditions may drive coping mechanisms like smoking, which can also lead to

a variety of chronic illnesses.3

Physically demanding jobs can also pose a challenge for meeting the public health

recommendations for physical activity. Data on levels of leisure-time physical activity and work-

related physical activity indicate differences across race, ethnicity, and socioeconomic status.12

In particular, lower levels of leisure-time physical activity were associated with education status,

which was lower for Blacks and Hispanics compared to Whites. Occupational physical activity

levels were greater among minority groups, suggesting that greater levels of physical activity at

work may reduce engagement in leisure-time physical activity.12 The role of physical fatigue is

one possible mechanism for such a relationship.

Immigrant status is also associated with lower levels of leisure-time physical activity and

higher BMI in Latinos.13 This may be due to physically demanding employment, adaption to

American culture and diet, and/or other factors. Latinos more frequently hold occupations that

require physical labor, which are generally of lower socioeconomic status.13 Given the diversity

in the present workforce, it is important to consider the role of physical demands at work when

promoting leisure-time physical activity for health benefits.

The food environment in the workplace can influence the types of food that workers

consume during breaks. The nutritional quality of meals can depend on workers’ accessibility to

healthy foods and eating facilities on job sites. Obviously, food choices are impacted by many

factors, including convenience, taste, cost, culture, and health status.14 However, working

conditions should not be overlooked. If the workplace has a designated break area with

refrigeration and heating equipment for food, workers have the ability to bring prepared food

from home. While some workers bring lunch from home, many tend to purchase lunch at least

one or more times a week.14 Common locations where food is purchased during lunchtime

include fast-food restaurants, on-site cafeterias, grocery stores, and vending machines,

especially for younger workers.14 Consequently, workplaces can play an important role in

supporting workers’ dietary intake.

Background

10

There is very little scientific research addressing the role of work factors in the etiology of

obesity, and even fewer studies have focused specifically on low-wage settings. The

investigation described in this report came about as a result of a community partnership

between the Massachusetts Coalition for Occupational Safety and Health (MassCOSH), an

advocacy organization dedicated to promoting safe and healthy working conditions, and the

University of Massachusetts Lowell, Center for the Promotion of Health in the New England

Workplace (CPH-NEW), an academic research center. Community members and workers

began approaching MassCOSH with stories about how their experiences in the workplace

influenced their body weight. In parallel, CPH-NEW was conducting studies to understand the

interplay between working conditions and health. Thus, both organizations found themselves

facing parallel research questions, including how the work environment might affect diet and

exercise, and how common such issues are among lower income workers.

Methodology

11

“Lifting the mattress andtucking in the sheets over 240times a day and bending downto clean up to 30 bathtubscauses us pain as we rush toclean 30 rooms.”

- “Maria,” housekeeper

Ninety percent of the hotelhousekeepers, includingMaria, took pain medicationregularly for injuries theyassociated with work, makingit possible for them to keepearning their living.

After taking the painmedication for severalmonths, Maria found thather weight had dramaticallyincreased.

MethodologyTo investigate how low-wage workers experience their jobs in relation to leisure-time

physical activity, eating patterns, and other behaviors related to body weight, a community-

based, participatory research team was formed. The research team consisted of faculty, staff,

and worker leaders from the Center for the Promotion of Health in the New England Workplace

(CPH-NEW) at the University of Massachusetts Lowell, the Massachusetts Coalition for

Occupational Safety and Health (MassCOSH), and the Boston Worker’s Alliance (BWA).

Based on a review of existing academic literature and anecdotal information shared by

Boston area workers, a focus group script was developed jointly by the research team.

MassCOSH and BWA work largely with Latino/a worker and Black/African American populations

respectively, so the materials utilized in the study were translated and back-translated between

English and Spanish. University personnel trained worker leaders on focus group facilitation

and the general research protocol, and worker leaders completed human subjects training

through the NIH, as required by the University to assure the protection of human subjects during

the research project. The UMass Lowell Institutional Review Board approved the project prior to

data collection, and an informed consent protocol was

followed with all participants.

Outreach workers from MassCOSH and BWA

recruited participants from Boston, Lawrence, and Lynn,

Massachusetts for the focus groups, with the assistance of

focus group facilitators. The goal was to recruit a variety of

individuals from multiple sectors of lower-wage employment

to participate in the focus groups. A recruitment flyer was

available in English and Spanish, and recruiters went to

various community meetings to discuss the project.

Individuals who were 18 years and older and employed in

hourly work at least twenty or more hours per week in the

past two years were eligible for participation in the focus

groups. Participants were also compensated $20 for their

contribution to the study.

Methodology

12

“We suffered for years while ouremployer stole money from ourwages and forced us to work indangerous conditions. I wasbeaten up by my supervisorand my co-workers also facedphysical and verbal abuses,”

- “Jose,” employee at awarehouse of a largesupermarket chain for 14 years.

Jose told MassCOSH that theinjury he suffered from hisassault caused him tobecome so depressed heneeded to take medication.His wife too becamedepressed and tookmedication. Joseexperienced weight gain andhis wife became morbidlyobese.

A facilitator from either MassCOSH or BWA and a co-facilitator from the University led

each focus group. A note-taker from the University also attended the focus groups and was

responsible for digital recordings. The focus groups were scheduled during evening hours and

weekends to avoid conflicts with participants’ work schedules. Demographic data on gender,

race, ethnicity, age, and job industry were collected voluntarily using a self-report form.

The script was designed to be covered in approximately 90 minutes. Workers were

asked to discuss their experiences with either gaining weight or difficulty losing weight and how

work played a role. Workers were also asked to report whether, in their own experience or that

of someone they knew, work-related injury, illness, assault or verbal abuse had an impact on

weight, eating patterns, and/or physical activities outside of the job. Workers had the

opportunity to provide recommendations regarding ways employers could modify the work

environment to support healthy behaviors, which allowed us to gain insight on the changes

lower-wage workers desire. Additional suggestions were also sought regarding how local

worker advocacy organizations can support and promote the changes suggested by workers.

CODING AND ANALYSISFocus group recordings were transcribed, and

facilitators and co-facilitators reviewed each focus group

transcript for accuracy. Analysis of the transcripts

consisted of compiling responses to each question posed

by the research team. Line-by-line coding was performed

to assist with the formulation of common themes among

focus groups. Further analysis of the focus group

transcripts to determine sub-themes was done using

qualitative data analysis software, QSR NVivo 9. The

results of the focus group data were presented to the

focus group facilitators and co-facilitators to ensure that

the findings coincided with their experiences during focus

groups and to determine if they noted other issues not

included in the summary.

Methodology

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INTERVIEWS AND COMMUNITY MEETINGSAfter the focus groups were completed, individual interviews were conducted with a

convenience sample of four new participants to obtain a more detailed picture of workers’

experiences in specific industries. The participants were identified and recruited for interviews

by worker leaders from MassCOSH and BWA, and these leaders conducted the interviews in

English and Spanish, as appropriate, in the spring of 2012. Results of these interviews are

highlighted as case studies in the “Worker’s Stories” section of this report.

The community organizations, MassCOSH and BWA, also held three stakeholder

meetings in the same communities where the focus group participants had been recruited. The

goal was to disseminate preliminary results for discussion, and to ascertain their implications for

community members and leaders. Approximately 25 additional Latina/o and African American

workers participated in these conversations. Some of the topics discussed at the stakeholder

meetings informed the “Recommendations” and “Workers’ Suggestions” sections of the report.

Results

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ResultsEight semi-structured focus groups were conducted between July and October 2011.

Each lasted about 90 minutes. Six of the focus groups were conducted in Spanish, while the

remaining two were in English. A total of 63 low-wage workers participated from various

industries (65% female, 35% male). The findings are summarized in this section, along with the

results of four in-depth interviews. The major themes and sub-themes are highlighted below and

developed in further detail on subsequent pages:

Workers reported feelings of exhaustion, having multiple jobs and responsibilities, andscheduling as elements of a heavy workload. Food was often used as a coping strategyto combat stress.

Having a physically demanding job often resulted in illnesses and/or injuries, influencingworkers’ ability to participate in leisure-time physical activity.

Exposure to job stressors (such as high demands) led some workers consume morehigh-calorie foods, such as candy and soda.

In restaurants, supervisors often decide the timing and length of meal breaks from dayto day. Irregular meal schedules and/or dictated breaks created anxiety about when onewould be able to eat.

Many workers reported having only 15 minutes to eat throughout their work schedule,making it more difficult to prepare and eat healthy food.

Workers reported having limited access to healthy food.

Many workplaces fail to provide workers with the appropriate equipment and space toeat meals, influencing workers’ diet.

Female workers often discussed the interaction between work and family, specificallyhow the combination of responsibilities at work and at home reduced available time toengage in physical activity and eat healthy. For these workers, reliance on conveniencefoods was a particularly important time-saving strategy.

Latino workers described low social support and its effect on overall health morefrequently than Black and African American workers did.

Results

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THEMES

Four primary themes were identified during the coding process to represent lower-wage

workers’ experiences in their jobs and workplaces and its relation to leisure-time physical

activity, eating habits, and other behaviors associated with body weight. Quotes from the

workers were selected by the investigators to illustrate each overall theme and component

sub-theme.

1. Physically demanding work

The consequences of working a job that requires substantial physical exertion were

frequently discussed throughout the focus groups. For these workers, physical demands

and hazards were often associated with some form of illness and/or injury.

“A friend of mine [construction]...a cinder block dropped on her foot…It broke herfoot...She was very active. Now she can’t do the jobs that she would normallydo...depression set in..."

“In housekeeping, we move way too much…my arm is sore and it hurts.”

“....He had to vacuum a lot, and had problems with his shoulder. He ate morebecause he was anxious he would lose his job…..he couldn’t work as fast…”

Working a physically demanding job made it challenging for workers to exercise or engage

in leisure-time physical activity at the end of a long workday.

“I don’t have the desire to do exercise after standing for 15-16 hours. I just wantto eat and sleep. The next day is the same thing all over again.”

“You come home and you are so tired that you either don’t want to eat, or youwant to eat a lot.”

2. Psychosocial stressors

Workers described job stressors associated with the mental and social aspects of their work,

including high demands, low control, and low levels of social support. These psychosocial

stressors have an impact on the quantity and pace at which foods are consumed, in addition

to their negative effects on overall health.

Results

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“The work that three people used to do is given to one person. That createsmore stress and eating more…”

“You think about deadlines and what you have to get done, so I don’t utilize thefull lunch hour to eat the healthiest meal.”

Those with low control in the workplace stressed the importance of keeping their job, which

often resulted in having less time to eat at work.

“Working in factories, you have to eat fast or you get fired.”

“…we had too much work so we didn’t have time for lunch. I needed thejob…sometimes I worked 10 or 12 hours…when I got home I ate fast food…”

Workers also reported experiences of conflict between co-workers or a poor relationship

with their supervisor. Having low social support at work not only created more stress for

these workers, but also increased feelings of anxiety, which, in many cases, led to

consuming more food.

“…he [the supervisor] yelled at me and it gave me anxiety and I would eat more.”

“A lot of harassment…it was really stressful so the depression really set in.”

3. Time pressure

Workers expressed challenges related to time available for maintaining a healthy diet and

incorporating physical activity into their daily routines. In particular, work schedules and

break times influenced workers’ eating patterns.

“At 10:00 a.m., they give me a 15-minute break. I don’t have time to eat healthyfood, even if I bring homemade food. I don’t have time to do exercise.”

“People that work the night shift don’t have a schedule for eating…a woman fromwork would say, ‘I gained weight because I eat at night.’”

Having multiple jobs and responsibilities had a major impact on whether some workers had

time to incorporate healthy behaviors, specifically in terms of food choice.

“Once you get home, you have to clean the house, do the laundry, and get thekids ready. Your job is not done. By the time you get time for you, it’s time totake care of your jobs all over again.”

Results

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“Rushing to the next job and wanting something quick…I buy a donut and coffeeto help keep me awake…”

4. Food environment at work

Workers discussed the physical aspects of the workplace that affect their options for food,

which were also influenced by the resources accessible to workers. When reporting

available food choices, workers said,

“Food from vending machines...soda. When we don’t have time to eat, we eatcrackers or chocolate.”

“They only have chicken fingers, hamburgers, and potato chips…it’s all the samefood everyday…”

Workers also expressed the lack of adequate eating facilities in the workplace, many

reporting little to no equipment (refrigerator, microwave, etc.) to eat meals brought from

home.

“I don’t have a microwave to heat up my food. I have to eat my food cold…”

“Many factories only have 1 or 2 microwaves, even though there are a lot ofemployees.”

Other workers stated either they had no space to eat their meals, or the designated break

area was not maintained or clean.

“I cannot even talk about the cafeteria because that ‘cafeteria’ is in a corner of adirty and unsanitary room.”

“I worked in a restaurant…there was no place to sit and eat…we would munchand move around.”

Results

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WORKER’S STORIES

In-depth interviews were conducted with four individuals to further investigate how

working conditions affect weight status among low-income workers. The following summaries

support the findings of our focus group research and further describe workplace factors that

affect workers’ weight and their ability to sustain a healthy diet and engage in physical activity.

ChristinaJanitor

Christina starts her day by making breakfast and preparing her lunch to bring towork. She spends about an hour and half on the train in the morning to get towork. She has about 30 minutes to eat lunch, typically eating salads, eggs,beans, meat, or chicken. By the time Christina gets home from work, it is about12:00am. She drinks a glass of milk when she gets home and goes to bed. Shesays she doesn’t exercise because she doesn’t have time and feels tired fromworking.

After being in the U.S. for three years, Christina has noticed that she has gainedweight. She says, “I think it’s from stress, and I’ve suffered from several illnessessince being in this country.” She’s had thyroid problems, high cholesterol,depression and anxiety, which she attributes to stress from work. Her supervisorwas verbally abusive, threatening Christina with termination.

Christina injured her foot on the job, which resulted in more stress at work, due tothe limitations posed by her injury. This also limited her ability to exercise, makingher gain weight. The combination of verbal abuse at work and sustaining aninjury has made Christina anxious and depressed. She has to take medication tomanage the depression, which is difficult to do on time because of her workschedule. Her work schedule also affects her eating patterns, limiting her to twomeals a day.

After Christina gained weight, her supervisor continued to be verbally abusive infront of others at work, saying, “People that are fat don’t last very long at work.”

Results

19

JuanConstruction Worker

Juan wakes up around 5:00 in the morning to get prepared for work, leaving by6:00am to arrive to work on time at 7:00. It takes Juan an hour to get to work,since he has to catch a bus, or sometimes two buses and a train. At work, Juandoes framing and sheetrock, and sometimes works up to 6 days a week to finishwhen behind at work. He can work up to 50 hours a week.

Juan says they have lunch at 3:00 in the afternoon, but if they are in hurry atwork, they are not allowed to stop to eat. Since there is a lot of dust on the jobsite, it often takes away his appetite and he leaves work feeling very tired in theafternoon. If Juan looks tired while working, his boss puts pressure on him towork faster.

When he has the opportunity to take a break, Juan spends 20-30 minutes eatinglunch. However, Juan does not bring food prepared from home because thereis nowhere to heat it up. He eats what is closest to the job site, which is oftenfast food. Juan says, “We go eat a pizza or if there’s a Dunkin Donuts, we drinka coffee, eat a donut to calm the hunger and keep going.”

By the time Juan gets home from work, it is usually 6:00 or 6:30pm. He eatsdinner at about 7:00pm, either eating eggs or buying fast food for dinner if he istired. Since transitioning to the U.S. and working in construction, Juan hasgained weight. He believes he has gained weight because of eating fast foodand not being able to exercise, due to an injury from work. Juan has had to takepain medication for his injury and has become depressed. Working hard andearning low wages has also contributed to Juan’s depression.

Juan was also diagnosed with cancer, which he believes may be from dust orchemicals at work. Thankfully, his cancer is in remission, but he has respiratoryproblems. His doctor also believes it is from exposure to dust at work, eventhough he has always worn a mask on the job. Living with this respiratoryproblem has been difficult for Juan. He says, “Sometimes my weight goes up,sometimes it goes down…I don’t know if it’s from the medicine, or eating fastfood…” Also, Juan has felt depressed because of his illness, especiallybecause he has to use a nebulizer and sometimes an oxygen tank to help himbreathe.

Results

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DarleneHuman Service Outreach Worker

Darlene wakes at 7:00am to dress and have a cup of coffee while getting hertwo children ready for school; she then leaves her house around 8:30am tohurry off to the office, which is 20 minutes away from where she lives. Sheworks at a woman’s drop-in center and her days are usually filled withconducting workshops, doing street outreach, and meeting with women whodrop in the center throughout the day from off the street. Darlene supports,educates, and trains the women on reducing risks associated with safety,reproductive health, sexual health, tobacco, breast health, and other healthtopics. This schedule leaves little time for her to incorporate breaks. The fastpace and constant attention to other people’s needs consumes her time at work.

Darlene says, “Because there are only fast food restaurants nearby the center, Ido not have much choice to eat healthily. When I do have time for a break, Igrab something quick because once I get to work I am constantly catering toother people’s needs”.

Around 5-5:30pm, Darlene says, she is “tired from a long day of meeting otherpeople’s needs.” Once she leaves the center, Darlene then picks up herchildren from the after- school program and heads home. Because Darlenedoes not make much money, she finds it a challenge to cook full meals for herand her family on a daily basis. Cooking and eating nutritiously can beexpensive; she buys what she can afford, not so much what is healthiest.

Darlene believes her weight gain and hypertension are connected to her eatinghabits. Eating better is challenging for her due to a fast-paced workenvironment and lack of money to afford healthier foods. Her co-workers havethe same eating habits (grabbing something convenient). This also creates abarrier to breaking bad eating habits, because it is not a supportive environment.

Although walking daily during street outreach provides low-impact exercise,without the support of eating the right foods this is not enough. Darlene hasdifficulty with breaking this cycle of eating fast foods and other non-nutritionalfoods, due to convenience and affordability.

Results

21

EvangelineHuman Service Outreach Worker/Case Manager

Evangeline typically wakes at 6:30am to watch the weather channel. Sheleaves her house around 7:30am to hurry off to her client appointments. Herusual day consists of meeting clients who live anywhere from 15 minutes to anhour away within the state of Massachusetts. Evangeline escorts her clients toand from their medical appointments. However, this daily caseload and hectictravel schedule leaves little time for lunch breaks that include healthy choices.

Evangeline says, “There are lots of fast food restaurants when traveling on theroad and most of them do not have many choices to eat healthy. When Ioccasionally have time for a lunch break, I grab something quick because I amalways rushing to get to the next appointment.”

At the end of the day, around 6:00-6:30pm, Evangeline says she is tired from along day of driving to and from appointments. She supports her daughter bypicking up her grandchild from school and then drops off the child at home, withhardly any time to cook dinner when she gets home. She will stop at the localgrocery store to grab a frozen dinner before going to bed. After a period ofeating fast foods regularly, she has begun to gain weight. Although sheattempts to eat yogurt or a trail mix bar to help get through the middle of the day,fast foods are more convenient and filling with a hectic work schedule.

Evangeline states she has difficulty with breaking this cycle of eating fast foodswhen on the road a lot, and does not have many options to change this habit.

Recommendations

22

RecommendationsTo enhance the working conditions reported by lower-wage workers in the study, the

following recommendations are aimed at employers, policy-makers and stakeholders:

Recommendations for Employers:

Breaks and Meals

Allow sufficient time for breaks and meals; provide the state-mandated 30 minutesconsecutively, as a single break.

Support daily communication of rest and meal break times to employees, to reduce anxietyabout hunger and to facilitate healthy meal planning.

Provide a clean space for eating, with sufficient functional equipment (refrigerator,microwave) for the number of employees on site.

Workload and Scheduling

Determine physical workloads that are moderate enough to avoid excessive fatigue and riskof injury.

Institute health and safety programs that identify and reduce or eliminate ergonomichazards.

Involve workers in scheduling decisions for shift work and overtime to promote familybalance and mental health.

Other

Encourage supportive supervisory and management styles.

Promote programs that identify and eliminate bullying and sexual harassment.

Select group health coverage and third party service contractors that address workingconditions and are sensitive to the needs of low-wage workers.

Establish worker-management committees that incorporate health, safety, and wellness.

Recommendations for Government and Public Policy-makers:

Address working conditions as part of workplace obesity or “wellness” programs.

When developing employer tools and resources for promoting employee health, includerecommendations and strategies for addressing working conditions that affect health.

Include occupational health experts in obesity reduction and other wellness advisorycouncils.

Recommendations

23

Increase funding for applied research on the impact of improved working conditions andmeal policies on obesity reduction.

Routinely incorporate information about occupation and industry in the Behavioral RiskFactor Surveillance Survey (BRFSS) and report on patterns of obesity by industry,occupation, and other demographic characteristics

Develop and implement a state-specific BRFSS module to collect additional information onworking conditions related to diet and exercise behaviors.

Recommendations for Insurance Companies

Establish insurance rate reduction programs for employers that improve workplace healthand safety. Extend these benefits to employers who make work environment improvementsthat affect obesity.

Track participation in Worksite Health Promotion by job type; Use this data to identify andaddress potential barriers to participation for low-wage workers.

Recommendations for Funders

Increase funding for intervention research on the impact of improved working conditions andmeal policies on obesity reduction, especially among low-income workers.

Promote funding for employer and worker initiatives that contribute to the improvement ofworking conditions to support good nutrition, physical activity, and psychosocially strongworkplaces.

Recommendations for Unions and Worker Groups

Educate workers about the impact of working conditions on weight, and engage them inparticipatory programs to increase the health status of lower income workers.

Establish union health and safety committees that integrate issues related to weight andwellness.

Recommendations

24

Workers’ SuggestionsDuring our focus groups and stakeholder meetings, we asked workers to provide input on ways

employers can support their efforts to maintain or achieve a healthy weight. Many of the

suggestions are mentioned in the “Recommendations” section; however, the suggestions below

were unique contributions, and it was deemed necessary to include them. Workers were also

asked for advice on how worker advocacy organizations or public policy-makers can assist them

in promoting these changes. Overall, it was notable that the workers perceived themselves to

have little power or influence over these rather fundamental workplace health issues.

The following represents a summary of workers’ suggestions:

Motivate employer action by developing a “business case” to illustrate the significantcosts (tangible and intangible) of having an overweight/obese lower-income workforce.

Offer a living wage to make lives less stressful.

Create a healthy worksite certification for employers and subsidize healthy foods in theworkplace with tax incentives for employers to promote employee wellness.

Conclusions

25

ConclusionsWorkers described direct experiences with many of the pathways cited in the literature

(physical, psychological, and behavioral).

Physical and psychosocial features of work were identified as important antecedents foroverweight.

In particular, non-traditional work shifts and working multiple jobs limit workers’ ability toadhere to public health recommendations for diet and physical activity.

Latino/a and Afro-American workers generally reported similar issues.

Qualitative methods provided valuable information about obstacles to healthy “lifestyle”choices.

Workers in all groups perceived themselves to be powerless to improve the conditionsthat negatively influence health.

Programs to address obesity in lower-wage workers must include the workenvironment as a fundamental starting point:

o Work organization, work scheduling, physical demands, and psychosocialstressors.

o Policies for mealtime and rest breaks.

o Clean, adequately equipped eating facilities.

o Strong health and safety protections.

Appendix

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APPENDIX

Focus Group DemographicsFaculty, staff, and worker leaders from the Center for the Promotion of Health in the New

England Workplace (CPH-NEW) at the University of Massachusetts Lowell, the Massachusetts

Coalition for Occupational Safety and Health (MassCOSH), and the Boston Worker’s Alliance

(BWA) coordinated and facilitated the focus groups. A total of 8 focus groups (2 English-

speaking, 6 Spanish-speaking) were conducted with 63 lower-wage workers in the Greater

Boston area.

TABLE: Characteristics of Lower-Wage Workers in Focus GroupsPercent of

SamplePercent of

Sample

Gender

Male 35% Female 65%

Race

American Indian/NativeAlaskan 13% Black or African

American 22%

White/Caucasian 30% Unknown 35%

Ethnicity

Hispanic or Latino 83% Non-Hispanic 14%

Unknown 3%

Age

18-24 5% 45-54 25%

25-34 33% 55-64 13%

35-44 21% 65-74 2%

Industries

Housekeeping/cleaning 17% Healthcare/humanservices 21%

Restaurant/food service 22% Manufacturing 13%

Construction 13% Other* 22%*business owner, community organizer, daycare, delivery driver, educational advisor, office work, sales, seamstress

Endnotes

27

Endnotes1 Caban, A. J., Lee, D. J., Fleming, L. E., Gómez-Marín, O., LeBlanc, W., & Pitman, T. (2005). Obesity in

US Workers: The National Health Interview Survey, 1986 to 2002. American Journal of PublicHealth, 95, 1614-1622. doi:10.2105/AJPH.2004.050112

2 Schiller, J., Lucas, J., Ward, B., & Peregoy, J. (2012). Summary health statistics for U.S. adults: NationalHealth Interview Survey, 2010. Vital and Health Statistics. Series 10, Data from The NationalHealth Survey, (252), 1-207.

3 Egerter, S., Dekker, M., An, J., Grossman-Kahn, R. & Braveman, P. (2008). Work Matters for Health.Robert Wood Johnson Foundation Commission to Build a Healthier America, Issue Brief 4:Work and Health. Retrieved from http://www.commissiononhealth.org/PDF/0e8ca13d-6fb8-451d-bac8-7d15343aacff/Issue%20Brief%204%20Dec%2008%20-%20Work%20and%20Health.pdf

4 Allen, T. D., Shockley, K. M., & Poteat, L. F. (2008). Workplace factors associated with family dinnerbehaviors. Journal of Vocational Behavior, 73, 336-342. doi:10.1016/j.jvb.2008.07.004

5 Devine, C. M., Farrell, T. J., Blake, C. E., Jastran, M., Wethington, E., & Bisogni, C. A. (2009). Workconditions and the food choice coping strategies of employed parents. Journal of NutritionEducation and Behavior, 41, 365-370. doi:10.1016/j.jneb.2009.01.007

6 Zunker, C., Cox, T. L., Wingo, B. C., Knight, B., Jefferson, W. K., & Ard, J. D. (2008). Usingformative research to develop a worksite health promotion program for African American women.Women & Health, 48, 189-207. doi:10.1080/03630240802313514

7 Escoto, K. H., French, S. A., Harnack, L. J., Toomey, T. L., Hannan, P. J., & Mitchell, N. R. (2010).Work hours, weight status, and weight-related behaviors: A study of metro transitworkers. International Journal of Behavioral Nutrition and Physical Activity, 7. doi:10.1186/1479-5868-7-91

8 Han, K., Trinkoff, A. M., Storr, C. L., & Geiger-Brown, J. (2011). Job stress and work schedules inrelation to nurse obesity. The Journal of Nursing Administration, 41, 488-495.doi:10.1097/NNA.0b013e3182346fff

9 Knutson K. L. (2010). Sleep duration and cardio metabolic risk: A review of the epidemiologicevidence. Best Practice & Research Clinical Endocrinology & Metabolism, 24(5), 731-43.

10 Schulte, P. A., Wagner, G. R., Blanciforti, L. A., Cutlip, R. G., Krajnak, K. M., Luster, M., & ... Ostry, A.(2007). Work, obesity, and occupational safety and health. American Journal of Public Health,97, 428-436. doi:10.2105/AJPH.2006.086900

11 Hall, J. C., Everett, J. E., & Hamilton-Mason, J. (2012). Black women talk about workplace stress andhow they cope. Journal of Black Studies, 43, 207-226. doi:10.1177/0021934711413272

12 He, X. Z. & Baker, D. W. (2005). Differences in leisure-time, household, and work-related physicalactivity by race, ethnicity, and education. Journal of General Internal Medicine, 20, 259-266.doi:10.1111/j.1525-1497.2005.40198.x

Endnotes

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13 Abraido-Lanza, A. F., Chao, M. T., & Florez, K. R. (2005). Do healthy behaviors decline with greateracculturation?: Implications for the Latino mortality paradox. Social Science & Medicine, 61,1243-1255. doi:10.1016/j.socscimed.2005.01.016

14 Blanck, H., Yaroch, A., Atienza, A., Yi, S., Zhang, J., & Mâsse, L. (2009). Factors influencing lunchtimefood choices among working Americans. Health Education & Behavior, 36, 289-301.doi:10.1177/1090198107303308